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Stepped care in psychological therapies: access, effectiveness and efficiency: Narrative literature review
Open accessAbstract
Background: There is a significant gap between the demand for psychological therapy services and the available supply. One proposal to overcome this problem is to increase efficiency of provision through the adoption of briefer ‘minimal interventions' within stepped care models. Aims: To examine the theoretical underpinnings of stepped care, together with the practicalities of the adoption of this system of care. Method: Narrative literature review. Results: The potential clinical and economic benefits of stepped care are dependent upon underlying assumptions of equivalence in terms of clinical outcomes, efficiency in terms of resource use and costs, and acceptability of ‘minimal interventions' to patients and therapists. Illustrative studies of these issues are considered. Conclusions: Although psychological services might benefit from the adoption of the stepped care model, a substantial research agenda needs to be fulfilled before a judgement can be made as to whether stepped care might be an efficient method of delivering psychological services.
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“but usually offered on an individual basis (Bower and Gilbody, 2005).”
From Do depressed and anxious men do groups? What works and what are the barriers to help seeking? (2014) · cites this paper as Bower and Gilbody, 2005
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“Therefore, treatment costs tend to be higher compared to primary care (Spijker et al., 2013) in combination with long waiting lists due to treatment duration and limited financial resources (Bower and Gilbody, 2005, Lovell and Richards, 2000).”
From Development and initial evaluation of blended cognitive behavioural treatment for major depression in routine specialized mental health care (2016) · cites this paper as Bower and Gilbody, 2005
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“Finally, the fact that few participants had previously consulted suggests that online interventions are attractive for first time consultations; they may demystify treatment and act as a stepping stone toward other more intensive intervention modalities (Bower and Gilbody, 2005).”
From Online and Mobile Interventions for Problem Gambling, Alcohol, and Drugs: A Systematic Review (2017) · cites this paper as Bower and Gilbody, 2005
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“Progress is monitored systematically and those patients who do not improve adequately step up to a treatment of higher intensity, thereby making the best use of available resources [7], although the steps perhaps do not make the best use of available clinical expertise [8].”
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“However, these staff reported that sometimes they would not refer for CBT because of long waiting lists, which is consistent with the point made by Bower & Gilbody (2005).”
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“Low-intensity programs, such as BEeT, are designed to be integrated within the early stages of a stepped-care model, either as a pure self-help intervention or a clinician-supported intervention [23, 73].”
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“Second, the model is “self-correcting” [8].”
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“These changes have already started to be implemented with the ideas of stepped care (Bower & Gilbody, 2005) and the psychosocial flavour of many recent mental health policies noted above.”
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BackgroundMental Health Care Models in Low-and Middle-Income Countries
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“Then, patients who go into remission following such minimal treatment receive no further treatment while others “step up” to a more intense form (e.g., professionally administered sessions; Bower & Gilbody, 2005).”
BackgroundTheoretical Foundations of Project Based Curricula in Higher Education
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“Creative solutions may be needed for intervention development and implementation, such as delivering interventions using eHealth technologies(36) and/or using stepped‐ care approaches to funnel resources to patients most in need.(37)”
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“However, unlike stepped care models that start all patients with the ‘‘least restrictive’’ treatment in terms of cost and patient inconvenience (Bower and Gilbody 2005), adaptive treatments are designed to match the patient to the type of treatment and dosage based on the patient’s needs such that some patients may be…”
InfluentialFive-Year Mental Health Care Use by Patients Referred to Collaborative Care or to Specialized Care
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“Studying how relationship repair attempts prior to therapy impact treatment may allow for the development of a stepped care approach for managing relational issues (see Bower & Gilbody, 2005 for a review of stepped care models in psychological treatments).”
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Integrated Management of Depression in the Elderly: Contributors
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Impact of graduate mental health workers upon primary care mental health: a qualitative study
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“Given the comparable dropout and retention rates across modalities, health systems may consider integrating guided ICBT as a scalable entry point in stepped-care frameworks (Bower & Gilbody, 2005), reserving face-to-face services for individuals requiring more intensive or personalized support.”
Barakat, S., & Maguire, S. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph20010119 · Cited by 17
“As part of the model, systematic monitoring of patients’ treatment progress is required so that, if clinically indicated, a “step up” of treatment intensity can occur in order to ensure that the low-intensity options are not counterproductive and leading to a worsening of symptoms [143,146].”
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Cunningham, N. R., Danguecan, A. N., Ely, S. L., Amponsah, Y., Davis, A. M., Edison, S., Harris, J. G., Jones, J. T., Goldstein‐Leever, A., Manning, A., et al. (2025) · Arthritis Care & Research · doi:10.1002/acr.25519 · Cited by 13
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Stepped-care versus treatment as usual in panic disorder: A randomized controlled trial
Kampman, M., van Balkom, A. J. L. M., Broekman, T. G., Verbraak, M. J. P. M., & Hendriks, G. (2020) · PLoS ONE · doi:10.1371/journal.pone.0237061 · Cited by 13
“The shared decision-making between patient and therapist is of importance to manage expectations and perhaps prevent dropping out in the first sessions [34].”
BackgroundEconomic evaluation of interventions for treatment-resistant depression: A systematic review
Hannah, L. A., Walsh, C. M., Jopling, L., Pérez, J., Cardinal, R. N., & Cameron, R. A. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1056210 · Cited by 14
“Such a model aims to address scarce treatment resources by ensuring that the most effective, least restrictive treatments (in terms of both healthcare resources, and patient convenience), are delivered first, with patients “stepped up” to more intensive treatments as needed (12).”
BackgroundBastiampillai, T. J., Jones, G. M., Furber, G., Moreau, M., Healey, D. F., Watson, J., & Battersby, M. (2014) · Australasian Psychiatry · doi:10.1177/1039856214530016 · Cited by 13
McClay, C.-A., Collins, K., Matthews, L., Haig, C. E., McConnachie, A., Morrison, J., Lynch, P., Waters, L., Day, I., McAnee, G., et al. (2015) · BMC Psychiatry · doi:10.1186/s12888-015-0384-2 · Cited by 13
“One of the aims of the stepped care model is to reduce waiting lists for individual therapy and increase the capacity and efficiency of services [6].”
BackgroundA Psychoeducational Approach to Hypochondriasis: Background, Content, and Practice Guidelines
Bouman, T. K., & Buwalda, F. M. (2008) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2007.11.004 · Cited by 14
“Bower and Gilbody (2005) discuss a number of requirements related to the clinical and economic evaluation of stepped care models.”
BackgroundHazell, C. M., Strauss, C., Hayward, M., & Cavanagh, K. (2017) · BMC Health Services Research · doi:10.1186/s12913-017-2449-z · Cited by 11
“Drawing on a stepped care approach [14], more resource intensive forms of CBTp could then be delivered only to those still in need.”
MethodIntervención psicológica escalonada con trastornos mentales comunes en Atención Primaria.
García-Sancho, J. C. M., Puerto, A. G., Egea, C., Diaz, G., Campillo, M.-J., & Espinosa, R. M. (2017) · Anales de Psicología · doi:10.6018/analesps.34.1.281491 · Cited by 13
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“The problem of not starting and not stepping up is common in stepped care [37,38].”
The Transportability and Utility of Cognitive Therapy in South African Contexts: A Review
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“…are offered to those with mild-to-moderate disorders and delivered by graduate mental health workers, while more intensive treatment is reserved for those with moderate-to-severe disorders and are delivered by more highly trained therapists, including psychologists (Bower & Gilbody, 2005).”
BackgroundMorse, A. K., Sercombe, J., Askovic, M., Fisher, A., Marel, C., Chatterton, M.-L., Kay-Lambkin, F., Barrett, E., Sunderland, M., Harvey, L., et al. (2023) · Journal of Substance Abuse Treatment · doi:10.1016/j.jsat.2022.108928 · Cited by 12
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Gupta, S. L., Wijk, K., Warner, G., & Sarkadi, A. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18041486 · Cited by 12
“Patients start with an evidence-based treatment of low intensity as a first step and those who do not respond adequately “step up” to a subsequent treatment of higher intensity [15].”
BackgroundActive Health Governance—A Conceptual Framework Based on a Narrative Literature Review
Zhang, K., & Ran, B. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19042289 · Cited by 12
“In this study, we conducted a narrative literature review, a literature review methodology informed by Greenhalth [14] Lloyd [15], Bower and Gilbody [16], Watters et al.”
MethodA Brief Psychoeducational Sexual Mindfulness Intervention to Bolster Sexual Well-Being
Dawson, S. J., Jang, G. E., & Goldberg, S. Y. (2022) · Mindfulness · doi:10.1007/s12671-022-01999-0 · Cited by 14
“Indeed, in line with stepped care approaches for mental health more generally (Bower & Gilbody, 2005), and relationships specifically (Busby et al., 2015; Markman et al., 2022), there is a need for brief psychoeducation programs to help individuals manage common challenges to their sexual…”
BackgroundBarriers in Access to and Delivery of Behavioral Sleep Treatments
Roberts, S., & Ulmer, C. S. (2023) · Current Sleep Medicine Reports · doi:10.1007/s40675-023-00270-9 · Cited by 15
Jones, E. A., Bale, H. L., & Morera, T. (2013) · The Cognitive Behaviour Therapist · doi:10.1017/s1754470x13000226 · Cited by 12
Gellatly, J. L., Bower, P., McMillan, D., Roberts, C., Byford, S., Bee, P., Gilbody, S. M., Arundel, C., Hardy, G. E., Barkham, M., et al. (2014) · Trials · doi:10.1186/1745-6215-15-278 · Cited by 12
“National Institute of Health and Clinical Excellence (NICE) guidelines for OCD [4] recommend the management of OCD using a stepped care approach [5].”
BackgroundSelf-citationSæther, S. M. M., Knapstad, M., Grey, N., & Smith, O. R. F. (2019) · Frontiers in Psychology · doi:10.3389/fpsyg.2019.02303 · Cited by 12
Using the Stepped Care Model to Empower University Students With Learning Disabilities
Jacques, J. G., & Abel, N. R. (2020) · Journal of College Counseling · doi:10.1002/jocc.12151 · Cited by 12
Investigating the Usability of Voice Assistant-Based CBT for Age-Related Depression
Striegl, J., Gotthardt, M., Loitsch, C., & Weber, G. (2022) · Lecture notes in computer science · doi:10.1007/978-3-031-08648-9_50 · Cited by 12
Miller, A. R., Gardiner, E., & Rosenbaum, P. (2023) · Springer eBooks · doi:10.1007/978-3-031-20792-1_42 · Cited by 13
Kenicer, D., McClay, C.-A., & Williams, C. (2012) · BMC Medical Informatics and Decision Making · doi:10.1186/1472-6947-12-102 · Cited by 12
“These are offered to those with non complex presentations and patients only ‘step up’ to longer (high intensity) specialist face to face therapy if improvements are not seen after a given time [5].”
BackgroundStepped Care, System Architecture and Mental Health Services in Australia
Perkins, D. A. (2016) · International Journal of Integrated Care · doi:10.5334/ijic.2505 · Cited by 12
“In 2016 the “National Disability Insurance Scheme” scheme is being implemented nationally to provide individually tailored care packages for those with enduring disabilities living in the community [15].”
BackgroundEerdenbrugh, S. V., Packman, A., Onslow, M., O’Brian, S., & Menzies, R. G. (2016) · International Journal of Speech-Language Pathology · doi:10.1080/17549507.2016.1257653 · Cited by 12
“Delivering health services with stepped care means first offering clients the most economical intervention that is likely to be effective, with practitioner input increasing only if required (Bower & Gilbody, 2005).”
BackgroundKarstens, S., Krug, K., Raspe, H. H., Wunderlich, M., Hochheim, M., Joos, S., & Hüppe, A. (2019) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-019-2467-6 · Cited by 12
Strudwick, G., McLay, D., Lo, B., Shin, H. D., Currie, L. M., Thomson, N., Maillet, É., Strong, V., Miller, A., Shen, N., et al. (2021) · Journal of Medical Internet Research · doi:10.2196/25773 · Cited by 11
Smoking status: A tacit screen for postpartum depression in primary care settings
Barber, G. A., & Shenassa, E. D. (2021) · Journal of Affective Disorders · doi:10.1016/j.jad.2021.09.033 · Cited by 22
Rees, C. S., Anderson, R., & Finlay‐jones, A. L. (2015) · BMJ Open · doi:10.1136/bmjopen-2014-007486 · Cited by 12
Oltedal, S., Garratt, A., & Johannessen, J. O. (2007) · Journal of Mental Health · doi:10.1080/09638230701279832 · Cited by 12
“It has been suggested that the aim should be to allow patients to have a role in treatment decision-making (Bower & Gilbody, 2005).”
BackgroundParent-Led, Therapist-Assisted, First-Line Treatment for Young Children After Trauma
Salloum, A., & Storch, E. A. (2011) · Child Maltreatment · doi:10.1177/1077559511415099 · Cited by 12
“Stepped care, as opposed to standard therapist-directed treatment where all patients receive the ‘‘full treatment package,’’ is designed to increase access to effective mental health treatment and to be more efficient and less costly than standard treatment (Bower & Gilbody, 2005).”
BackgroundAlili, M. E., Schuurhuizen, C. S. E. W., Braamse, A. M. J., Beekman, A. T. F., van der Linden, M. H., Konings, I. R. H. M., Dekker, J., & Bosmans, J. E. (2020) · Palliative Medicine · doi:10.1177/0269216320913463 · Cited by 12
Abdalla, T., Singh, G. K., Roudbaneh, S. P., Serwaa, D., & Peate, M. (2025) · JNCI Journal of the National Cancer Institute · doi:10.1093/jnci/djaf153 · Cited by 14
Levels of Meaning and the Need for Psychotherapy Integration
Wakefield, J., Baer, J., & Conrad, J. A. (2020) · Clinical social work journal · doi:10.1007/s10615-020-00769-6 · Cited by 10
Staeck, R., Drüge, M., Albisser, S., & Watzke, B. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100555 · Cited by 9
“Possible reasons are a preference for self-help (Kessler et al., 2001), stigmatization (Collins et al., 2004) and limited availability of evidence-based treatment (Bower and Gilbody, 2005).”
Fernandes, G. J., Choi, A., Schauer, J. M., Pfammatter, A. F., Spring, B. J., Darwiche, A. Y., & Alshurafa, N. I. (2023) · Journal of Medical Internet Research · doi:10.2196/42047 · Cited by 15
Ekers, D., & Webster, L. A. D. (2012) · Journal of research in nursing · doi:10.1177/1744987112466254 · Cited by 11
“Many guidelines recommend a stepped care approach; however, there is clearly insufficient evidence as to the clinical and cost effectiveness of this model (Bower and Gilbody, 2005a) or the ideal systems that facilitate people’s movement into and through it (Bower and Gilbody, 2005b).”
BackgroundAcceptability of a Positive Parenting Programme on a Mother and Baby Unit: Q-Methodology with Staff
Butler, H., Hare, D. J., Walker, S., Wieck, A., & Wittkowski, A. (2016) · Journal of Child and Family Studies · doi:10.1007/s10826-016-0564-9 · Cited by 11
“2013), in particular for working with mental health difficulties and stigma on which staff have received minimal guidance (Bower and Gilbody 2005).”
BackgroundCost-Effectiveness of a PTSD Intervention Tailored for Individuals With Severe Mental Illness
Slade, E. P., Gottlieb, J. D., Lu, W., Yanos, P. T., Rosenberg, S. D., Silverstein, S. M., Minsky, S. K., & Mueser, K. T. (2017) · Psychiatric Services · doi:10.1176/appi.ps.201600474 · Cited by 11
“This raises the question of whether the BRF intervention is itself an effective intervention, and suggests the possibility of stepped PTSD treatment (22, 23), wherein the BRF intervention would be offered as a first-line therapy followed by CBT-P for individuals whose PTSD symptoms do not remit.”
MethodIntroducing the comprehensive pain management editorial series
Nijs, J., & Lahousse, A. (2023) · Brazilian Journal of Physical Therapy · doi:10.1016/j.bjpt.2023.100506 · Cited by 13
Liang, M. Z., Liu, M. L., Tang, Y. C., Molassiotis, A., Knobf, M. T., Chen, P., Hu, G. Y., Sun, Z., Yu, Y. L., & Ye, Z. (2023) · European Journal of Oncology Nursing · doi:10.1016/j.ejon.2023.102374 · Cited by 11
Asano, K., Ishimura, I., Abe, H., Nakazato, M., Nakagawa, A., & Shimizu, E. (2015) · Open Journal of Medical Psychology · doi:10.4236/ojmp.2015.41002 · Cited by 10
“The least restrictive therapy should be a readily accessible form of treatment, provided at the lowest cost, least personal inconvenience to patients, requiring the lowest treatment intensity and least specialist time [32].”
BackgroundIs duration of psychological treatment for depression related to return into treatment?
Boerema, A. M., Cuijpers, P. J., Beekman, A. T. F., Hellenthal, A., VOORRIPS, L. E., & van Straten, A. (2016) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-016-1267-7 · Cited by 13
“Furthermore, many guidelines recommend low intensity treatment as a first step in the treatment of mild to moderate depression [8–10] and provide more intensive treatment only to people who do not respond to low intensity treatments [11].”
BackgroundShepherd, M. A., & Rosairo, M. (2008) · PubMed Central · Cited by 11
Metadata
- Authors
- Bower, P., & Gilbody, S.
- Affiliations
- University of Manchester (GB)
- University of Leeds (GB)
- Corresponding author
- Bower, Peter
- Venue
- British Journal of Psychiatry
- Publisher
- Royal College of Psychiatrists
- Published
- 2005-01
- Volume
- 186
- Issue
- 1
- Pages
- 11-17
- ISSN
- 0007-1250 (ISSN-L)
- 1472-1465
- OpenAlex
- W2160548159
- Cited by
- 1,084
- References
- 66
- Citations by year
- 2026: 76 · 2025: 61 · 2024: 71 · 2023: 72 · 2022: 73 · 2021: 62 · 2020: 68 · 2019: 63 · 2018: 65 · 2017: 51 · 2016: 62 · 2015: 55 · 2014: 48 · 2013: 45 · 2012: 54
- FWCI
- 3.42
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The British Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Research Explorer (The University of Manchester) (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Keywords
- stepped care, psychotherapy, minimal intervention, brief intervention, access to mental health care, service supply and demand, treatment efficiency, cost-effectiveness, treatment acceptability, resource utilization (health care)
- MeSH terms
- Mental Disorders, Humans, Patient Acceptance of Health Care, Psychotherapy, Treatment Outcome
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